Shower Transfer Chair Assessment Form
Comprehensive assessment to determine the need and suitability for a shower transfer chair.
Client Full Name
*
First Name
Last Name
Date of Assessment
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Assessor Name and Position
*
Contact Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Client Mobility and Transfer Abilities
*
Rows
Independent
Needs Supervision
Needs Assistance
Unable
Bed to Chair Transfer
1
2
3
4
Standing Balance
5
6
7
8
Sitting Balance
9
10
11
12
Ability to Follow Instructions
13
14
15
16
Current Equipment Used in the Bathroom
None
Grab Bars
Shower Chair (Standard)
Transfer Bench
Commode Chair
Other
Bathroom Environment Details
*
Rows
Yes
No
Not Applicable
Walk-in Shower
17
18
19
Bathtub Present
20
21
22
Adequate Space for Chair
23
24
25
Non-slip Flooring
26
27
28
Potential Safety Risks or Concerns
Slippery Surfaces
Limited Space
Obstacles in Access Route
Water Temperature Control
Other
Client's Goals and Preferences for Showering
Recommended Shower Transfer Chair Features
Adjustable Height
Padded Seat/Backrest
Removable Armrests
Wheels with Locks
Cut-out Seat
Other
Additional Comments or Recommendations
Assessor Signature (Type or Draw)
*
Submit Assessment
Submit Assessment
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